Roxanne Dryden-Edwards, MD

Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

Duck syndrome facts

Although not a formal mental-health diagnosis, duck syndrome has mostly been described in college or graduate students and refers to the situation in which the sufferer looks completely calm on a superficial level while in reality they are frantically trying to keep up with the demands of their life.

Risk factors for duck syndrome are thought to include the specific and the general, in that the stress of the college environment, personal and family tendencies to excessively emphasize achievement, as well as family overprotection are considered specific risk factors and the risk factors for depression, anxiety, and mental illness in general can be considered more general factors that can predispose a person to developing duck syndrome.

While there are no formal diagnostic criteria for duck syndrome, symptoms that have often been described include appearing placid on a superficial level while frantically yet covertly failing in their attempts to keep up with the overwhelming demands placed upon them; feeling that everyone else is faring better than him- or herself, that others are scrutinizing, or even designing the situation to test their performance.

Since duck syndrome is not a formal diagnosis, the underlying depression, anxiety, and any other mental-health problem would be assessed. That involves a health professional ensuring a thorough medical assessment and conducting a comprehensive mental-health evaluation.

The combination of psychotherapy and medications are mainstays of treatment of depression and anxiety and therefore should be considered in alleviating duck syndrome.

Without treatment, people with duck syndrome, like those who suffer from depression and anxiety, are at risk for developing medical problems, other mental-health issues, disability, and early death.

Stress Management

What are the symptoms and effects of excess stress or "out-of-control" stress?

Manifestations of excess or poorly managed stress can be extremely varied. While many people report that stress induces headaches, sleep disturbances, feelings of anxiety or tension, anger, or concentration problems, others may complain of depression, lack of interest in food, increased appetite, or any number of other symptoms. In severe situations, one can experience overwhelming stress to the point of so-called "burnout," with loss of interest in normal activities.

What is the definition of duck syndrome?

Duck syndrome, also referred to as the Stanford duck syndrome or ugly duckling syndrome, is not formally recognized as a mental illness but refers to a phenomenon that has primarily been described in college students. Specifically, it is thought to afflict students who are overly invested in looking like they have it all together, and like a duck, appear to be calm and placid on a superficial level but are paddling frantically to "stay above water" in terms of meeting the academic, social, and community demands of getting a college education or beyond. Duck syndrome seems to be one way that depression, anxiety, or the initial stages of many mental illnesses can appear (manifest), usually in reaction to stress. Due to the known potentially devastating consequences of depression or anxiety, duck syndrome should be taken quite seriously and aggressively treated.

What are causes and risk factors for duck syndrome?

Specific risk factors for duck syndrome are thought to include many aspects of the college experience, including living away from family for the first time, a significant increase in academic and extracurricular demands compared to high school, as well as the social pressure associated with attending college. Additional theories about potential risk factors and causes of duck syndrome include the pressure that social media can place on young adults to appear to be achieving effortless perfection as a student despite all of the pressures thereof. Family risk factors that are thought to be specific for duck syndrome include a tendency to be demanding and highly competitive, placing high value on perfection, and parents who are overly protective of children such that the children have minimal experience with disappointment, resilience, and at accepting their challenges as well as their strengths. Such a parenting style is sometimes referred to as helicopter parenting, in that the parents tend to hover and excessively intervene in their children's lives.

Given the likely relationship between duck syndrome and mental illnesses, particularly with depression and anxiety, the risk factors for those conditions should be considered to be predisposing factors for duck syndrome, as well. Like most emotional conditions, the depression and/or anxiety associated with duck syndrome does not tend to have one specific cause. Rather, people with this condition usually have a number of biological, psychological, and environmental contributors to its development. Biologically, depression, anxiety, and therefore perhaps duck syndrome can be associated with abnormal levels of neurotransmitters in the brain, a smaller size of some areas of the brain, and increased activity in other parts of the brain. Girls and women are more likely to be given a diagnosis of depression and many anxiety disorders compared to boys and men, but that is thought to be due to, among other things, biological differences based on gender and differences in how females are encouraged to interpret their experiences and respond to them compared to males. There is thought to be at least a partially genetic component, and people with a depressed or anxious parent are more likely to also develop the disorders. These issues are therefore likely to pertain to the development of duck syndrome.

As with the previously described contributors to the development of duck syndrome, psychological contributors to depression and anxiety include perfectionism, low self-esteem, negative body image, being excessively self-critical, and often feeling helpless when dealing with negative events. People who suffer from conduct disorder, attention-deficit hyperactivity disorder (ADHD) or who have cognitive or learning problems, as well as trouble engaging in social activities also are have more risk of developing depression and anxiety so should be considered at potentially higher risk for developing duck syndrome.

Like other manifestations of depression and anxiety, duck syndrome may be a reaction to life stresses that predispose a person to developing any mental illness. Examples of such risk factors may include trauma, like being the victim of verbal, physical, or sexual abuse; exposure to domestic violence, the death of a loved one, school problems, being bullied, or being exposed to peer pressure. In addition to the more specific risk factors for depression and anxiety previously described, other potential contributors to this condition include poverty, exposure to community violence, social isolation, parental conflicts, divorce, and other causes of family disruptions. Children who have limited physical activity, poor school performance, or lose a relationship are at higher risk for developing depression, anxiety, and therefore to developing duck syndrome, as well.

What are duck syndrome symptoms and signs?

Due to the informality of this diagnosis, there are no formal diagnostic criteria associated with duck syndrome. However, symptoms that have often been described include appearing placid on a superficial level ("above water") while frantically yet covertly ("under water") failing in one's attempts to keep up with the real or imagined excessive demands (to keep from "drowning"). Other often-described symptoms associated with duck syndrome include feeling that everyone else is doing, feeling, or being well compared to oneself, or that others are scrutinizing or perhaps even designing the situation to test their performance.

How do health-care professionals diagnose duck syndrome?

Since duck syndrome is not a formal diagnosis, it is the underlying depression, anxiety, and any other mental-health problem that would be assessed.

Depression or anxiety are associated with a number of other mental-health conditions, like attention-deficit hyperactivity disorder (ADHD), bipolar disorder, posttraumatic stress disorder (PTSD), and thought disorders like schizophrenia, so the evaluator will likely screen for signs and symptoms of manic depression (bipolar disorder), a history of trauma, and other mental-health symptoms. The depression or anxiety that is usually associated with duck syndrome also may be associated with a number of medical problems, or it can be a side effect of various medications, exposure to drugs of abuse, or other toxic substances. Therefore, routine laboratory tests are often done during the initial assessment to rule out other causes of symptoms. Sometimes, an X-ray, scan, or other imaging test may be needed. As part of the evaluation, the sufferer may be asked a series of questions from a standardized symptom survey or self-test to help determine the risk of suicide.

What types of specialists treat duck syndrome?

A number of mental-health practitioners tend to evaluate an individual who is thought to have duck syndrome. Such professionals include licensed mental-health counselors, pediatricians, other primary-care providers, specialists who treat patients for a medical problem, emergency-department doctors, psychiatrists, psychologists, psychiatric nurses, nurse practitioners, physician assistants, and social workers. These professionals will likely perform or refer for a thorough medical evaluation as part of assigning the correct diagnosis.

What is treatment for duck syndrome?

Treatment for duck syndrome may include alleviating any medical condition that causes or worsens the associated depression, anxiety, or other mental illness. For example, a person who is found to have largely fluctuating blood sugar levels might receive medication to keep their blood sugar levels stable. Other aspects of treatment may include supportive therapy, like lifestyle and behavioral changes, psychotherapy, and possibly medication for moderate to severe emotional symptoms. If symptoms are severe enough that treatment with medication is appropriate, the individual will likely improve faster, more robustly, and for longer when medication is combined with psychotherapy.

Psychotherapy ("talk therapy") is a kind of mental-health counseling that entails working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerfully effective intervention, even resulting in positive biochemical changes in the brain. Two major kinds of psychotherapy are commonly used to treat depression, anxiety, and other mental-health conditions and are therefore likely an effective intervention for duck syndrome: interpersonal psychotherapy and cognitive behavioral therapy. In general, these forms of treatment take weeks to months to complete and have a goal of alleviating depressive or anxiety symptoms. More intensive psychotherapy may be needed for longer when treating very severe mental-health symptoms.

Interpersonal therapy (IPT): This form of psychotherapy seeks to alleviate depressive or anxiety symptoms associated with duck syndrome by helping the sufferer develop more effective skills for coping with their emotions and relationships. IPT uses two strategies to achieve those goals:

Educating the person about the nature of their emotional symptoms: The therapist will reassure the sufferer that stress is a common phenomenon and that most people tend to improve with treatment.

Defining problems (such low self confidence or relationship problems): Once problems are defined, the therapist can help the individual set realistic goals for solving these problems and work with him or her using different treatment techniques to reach these goals.

Cognitive behavioral therapy (CBT): This approach to psychotherapy can help decrease the depression or anxiety that often presents as duck syndrome and the likelihood it will come back by helping a duck syndrome sufferer change his or her way of thinking about certain issues. In CBT, the therapist uses three techniques to achieve these goals.

Didactic component: This phase helps to establish positive expectations for treatment and promote the person's investment in the treatment process.

Cognitive component: This encourages understanding the thoughts and assumptions that play a role in the individual's behaviors, especially those that may predispose the sufferer to being depressed, anxious, or otherwise stressed.

Behavioral component: This uses behavior-modification techniques to teach the duck syndrome suffer healthier, more effective ways of coping with problems.

The most commonly used group of antidepressant/antianxiety medications prescribed is the selective serotonin reuptake inhibitors (SSRIs). SSRI medications influence the levels of serotonin in the brain. For many prescribing practitioners, these medications are the first choice because of the significant degree of effectiveness and safety of this group of medicines.

What are complications of duck syndrome?

Without treatment, symptoms of anxiety, depression, most other mental illnesses tend to last much longer, may not improve, or may worsen. Given the association of duck syndrome with emotional problems, that is likely true of that phenomenon as well. With treatment, the chances of recovery are therefore likely significantly improved.

Depression and anxiety put sufferers at risk for developing a number of other mental-health issues. For example, individuals with either of those issues are also more likely to have poor academic or job performance, to engage in substance abuse, and to experience family and other relationship problems.

What is the prognosis for duck syndrome?

Since duck syndrome is often a manifestation of depression or anxiety, the outcomes for those conditions need to be considered. Depression can be chronic, in that 85% of people who have one episode of the disorder will have another one within 15 years of the first episode. People with depression or anxiety are at greater risk for developing other forms of mental illness, disability, or even death.

Is it possible to prevent duck syndrome?

Ways to prevent stress and the effects thereof, including duck syndrome in college students, are thought to include a robust orientation for new students regarding stress management and mental-health services; highly available peer outreach groups; increased attention for students who may be at higher risk for isolation (for example, those who are the first to attend college in their families, may not be involved with any organized activity through their college, or be a minority based on gender, race, religion, sexual orientation, or any other basis); supportive relationships between college students and their dormitory staff; well-implemented procedures for helping students who are in crisis; and the availability of comprehensive mental-health services. Academic supports, including regular academic counseling and academic mentoring, as well as tutoring services are also potential ways to prevent the development of duck syndrome.

American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive
Disorder, Third Edition. Arlington, Virginia: American Psychiatric Association, October 2010. <https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf>.